Timeline of a crisis

June 9, 2006

Haywood Regional Medical Center receives a visit from the Department of Health and Human Services Division of Medicaid and Medicare Services, the state agency responsible for overseeing hospital compliance with standard of care requirements. Inspectors cite the hospital for its lack of adequate and qualified nursing staff after determining there was a failure to provide nursing treatment pursuant to doctors’ orders for six out of seven patients reviewed. Two of six nurses held out-of-date RN licenses, according to inspectors. In two cases, nurses restrained a patient without physician’s orders — one an unconscious victim of alcohol poisoning.

The report also cites a lack of adequate and qualified intensive care unit staff, leading to a failure to monitor conditions and medication errors. In one case, a 66-year-old woman with a bowel obstruction was given the incorrect blood pressure medicine even after a change was noted on the patient’s chart. The staff member who made the error admitted to it in an interview with state inspectors and claimed to have filed a report, which was never located. In another case, an 84-year-old male with chest pain and kidney failure received an incorrect low dosage of medicine over the course of an hour which should have been administered every minute. The mistake was recognized when his IV bag was found empty and beeping.

In both above instances, nurses attributed the mistakes to a lack of staff available to care for patients. These concerns were echoed by other nurses interviewed by inspectors. “There are many nights they take more patients than they feel is safe,” said one. A nurse in the ICU overloaded with more patients than she could care for described being threatened with termination if she refused to take another patient.

Another gave this account: “Phones ringing off the hook with no one to answer them. Families everywhere ... some even commented on our lack of help. A family member came to the door of my patient’s room ... to say, ‘Is no one going to help my mother, the IV is beeping.’ Now there is an image to portray to the public! Why is this allowed to continue, and who will have to die before someone does something??”

Aug. 25, 2006

DHHS inspectors visit the hospital, again finding instances of problems with nursing care. Patients are still being restrained without a physician’s orders, and inspectors cite a lack of RN supervision. In one case, a patient in the emergency department was reported missing three hours after coming in complaining of severe pain in his inner thigh, the intensity of which he described as a 10 on a scale of 1 to 10. An interview with nursing administrative staff reveals that no reassessment of the patient was documented, although emergency department patients should be reassessed every two hours at a minimum, and more frequently if the patient has a pain level of 10.

Inspectors again report problems with administration of medication. A 21-year-old mentally unstable female with a history of substance abuse is admitted with tremors, and improved significantly after being given the oral medication Ativan. A physician’s note ordered that six doses of the drug be administered every four to six hours. A second dose was never given, and nurses couldn’t give a reason why orders were not followed.

In another case, a patient was given two medications back to back, both of which she was allergic to. Her allergies had been documented a year earlier during a previous hospital visit, and were in the pharmacy’s computer system. The report states that the patient was given six doses of the drug even though pharmacists alerted nurses to the allergy.

Inspectors also docked the hospital for having expired drugs, some dating back to 2003.

Oct. 24, 2007

Inspectors again visit the hospital, this time citing HRMC for failing to recognize patient rights in the process of filing grievances in the hospital. A prominent example given in the report is that of a 69-year-old female admitted to the hospital with a diabetic foot ulcer. The patient was discharged with an intraveneous catheter still in the patient’s arm, which was removed at home by a family member with medical training. When the family called to complain, their voicemail message was not returned and no grievance was documented.

Jan. 31, 2008

State inspectors visit HRMC to conduct another survey, this time as a result of a complaint reported to the agency regarding incidents occurring on Nov. 11, 2007. The state agency finds that the nursing facility staff “failed to administer medications as ordered by the physician as evidenced by the omission of a critical drug in the hospital’s intensive care unit.” The hospital is tagged with Immediate Jeopardy (IJ) identification.

Feb. 7, 2008

A letter is faxed to HRMC CEO David Rice from the Division of Survey and Certification — the federal agency in charge of overseeing compliance with Medicare care regulations — notifying him of the Immediate Jeopardy identification. The hospital has 23 days to correct the problem and detail a plan of action to make sure it doesn’t happen again. If HRMC fails to do so, it will lose the ability to bill for Medicare inpatient services. Medicare patients make up 57 percent of HRMC’s client base.

Feb. 12, 2008

Another letter is sent to Rice from the Atlanta headquarters of the Department of Health and Human Services Center for Medicare and Medicaid Services. It states that in addition to the IJ identification determined during the Jan. 30-Feb. 1 survey, the hospital has been cited for four other deficiencies “that could potentially affect the health and safety of patients.” These are: Governing Body, Quality Assessment and Performance Improvement, Nursing Services and Pharmaceutical Services. Essentially, surveyors have determined that the hospital is poorly run, lacks oversight, has inadequate care provided by nurses, and fails to properly administer and store medication. The letter states that termination of Medicare funding can only be avoided if the hospital corrects the deficiencies by Feb. 24, 2008.

Feb. 19, 2008

The Division of Survey and Certification responds to HRMC’s contention that the deficiencies at HRMC have been corrected. The letter states that a follow up survey of Medicare conditions will be conducted at the hospital.

Feb. 19-22, 2008

A state survey team revisits HRMC.

Feb. 22, 2008

The survey team determines that problems with medication administration have not been corrected and recommends the Immediate Jeopardy identification stay in place. The team also finds that the hospital continues to be out of compliance with the four deficiencies they were cited for during the Jan. 31 inspection. In addition, three new deficiencies are found: Patients Rights, Infection Control, and Respiratory Care Services.

Feb. 23, 2008

The Division of Survey and Certification in Atlanta emails Rice a letter notifying him of the state survey team’s findings. The letter states that termination of the Medicare program is effective Feb. 24, 2008.

Feb. 23, 2008

In an email and fax, Rice contests the Division of Survey and Certification’s findings from the letter received earlier this day. “HRMC has taken significant corrective action since your latest visit by re-educating nurses and other health care providers, continuing observations, ongoing auditing of records and engaging the assistance, recommendations and oversight of personnel from Mission Hospital, Inc.,” the CEO states. Rice also says that Xygris, the drug that was the subject of the IJ medication administration matter, has been removed from the hospital. He requests that the state agency re-survey HRMC.

Feb. 24, 2008

State inspectors comply with Rice’s request to re-survey the hospital.

Feb. 25, 2008, 2 a.m.

The survey team announces that the hospital’s Medicare program will not be reinstated. In addition, the team yanks HRMC’s Medicaid funding. Reports listing the details of what was found during the Feb. 25 survey are not expected to be available until later this week.